Pavilion Of Ottawa
704 East Glover Street, Ottawa, IL 61350 · For profit - Individual · 135 certified beds · (815) 434-7144 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.4% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 69.9% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.4% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.4% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.6% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.3% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.8% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.0% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.97 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.88 | 2.22 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 193 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 22.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 81 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.9%CMS range 48.4–60.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.3–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 22.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 22.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 93.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.1–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 135 beds and averages 128.3 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 3.72 on weekdays — 14% thinner on weekends. RN hours go from 0.78 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · Gcited before2025-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to identify fall risks and follow policy and procedures to prevent falls for two (R1 and R2) of three residents reviewed for falls in the sample of three. These failures resulted in R1 falling from wheelchair to the floor, bleeding, pain, bruising, and hospital visit with a diagnosis of nasal fracture and receiving sutures. These failures also resulted in repeat falls for R2. Findings include: The facility's undated Fall Management policy and procedure documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident and his or her family and staff regarding significant risks related to a resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a grievance was resolved for 1 of 3 residents (R3) reviewed for resident's rights in the sample of 14.The findings include:On 2/20/26 at 10:33 AM, V8 (R3's daughter) said last month, she had brought a concern regarding R3's missing tooth (two natural teeth) to staff including V1 (Administrator) and V2 (Director of Nursing). V8 said no one can tell her what happened to R3's missing tooth or how R3 lost her tooth. Did it just come off in her mouth? What caused it to fall off? V8 said as of today, no one yet (at the facility) came back to tell her what happened.On 2/20/26 at 12:30 PM, V11 (CNA) said a couple of weeks ago, she noticed R3 tapping her mouth, she has dementia so she cannot speak, it looked like she lost a tooth. V11 said this was reported to the Nurse who said she will refer R3 to the dentist.R3's progress notes dated 1/27/26 documents, Oral visual check done, deny pain and discomfort, no redness or swelling on her gums noted. 1 right lateral tooth noted missing. daughter aware.On 2/20/26 at 12 PM, V2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent cross-contamination. This failure has the potential to affect all 124 residents in the facility.The findings include:The CMS (Centers for Medicare and Medicaid Services) form 671 dated 8/26/2025 showed 124 residents resided in the facility.On 8/27/2025 at 8:20 AM, V2 (Director of Nursing) said the facility did not have any residents with a feeding tube. On 8/26/2025 between 9:45-10:15 AM, while doing the initial Kitchen observation, a scoop was left inside of the large container of thick-it (a powder used in food preparation to thicken food consistency). The scoop was directly on the powder mixture. The handle was touching the powder.On 8/26/2025 at 11:09 AM V11 (Cook) prepared the pureed foods (hamburger patties) for the lunch meal, then separated the pureed meat into several small pans for the different halls they were to be served on. V11 picked up half of the pans and held them against her clothing when she was taking them to put in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with shaving facial hair for 3 female residents (R48, R57, R65) and failed to provide assistance with grooming, shaving and denture care for 1 resident (R131). This failure affected 4 of 4 residents (R48, R57, R65, R131) reviewed for activities of daily living in the sample size of 49.The findings include:1. On 08/26/2025 at 11:56 AM observed R48 seated in a wheelchair at the nurse's station on the 800 unit and noted facial hair to chin area that appeared thick and course and was approximately 4-5 milliliters in length. R48 indicated that the girls help me with her chin hair. No aides were observed present on unit at this time.On 08/27/2025 at 12:14 PM, observed R8 seated at the dining room table on the 800 unit and noted facial hair to her chin area that appeared thick and course that was approximately 2-3 milliliters in length at this time.R48's face sheet showed an admission date of 05/14/2025 with a past medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure multiple insulin pens and a vial of liquid morphine were properly labeled with an open and discard date in accordance with professional standards. This failure affected 6 of 6 residents (R5, R8, R41, R74, R82, R94) reviewed for medication storage in the sample size of 49. The findings include: On 8/27/2025 at 10:38 AM, R94's long-acting prefilled insulin pen had a yellow sticker with a spot to document Date Open, Date Exp (expired), and initials. The sticker was not filled out or initialed. The cap for the pen had a tamper resistant red tape which indicated the pen had been opened. V4 Licensed Practical Nurse (LPN) stated she had given R49's long-acting insulin that morning and the pen had already been previously opened and used prior to the morning of 8/27/25. On 08/27/2025, medication storage and labeling task was performed by this surveyor with V6 (Registered Nurse) on the 800 unit with the following findings. At 12:22 PM, observed two glargine insulin pens for R82 and one glargine (lantus) insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the device used to check residents' blood sugar levels (a glucometer) was disinfected according to the manufacturer's instructions, to prevent cross-contamination for 9 of 9 residents (R3, R10, R13, R20, R34, R40, R75, R107, and R127) reviewed for glucose checks in the sample of 49.The findings include:On 8/26/2025 at 12:13 PM, V15 (Licensed Practical Nurse-LPN) performed a blood glucose test on R127 prior to the lunch meal. After checking R127's blood sugar level, V15 used a micro-kill disinfectant wipe to clean the glucometer. V15 did one swipe across the glucometer, then place the glucometer on a tissue that was on the medication cart. At 12:26 PM, V15 used the same glucometer to check R3's blood sugar level prior to the lunch meal. After obtaining the blood sample, V15 placed the glucometer on the windowsill in R3's room. V15 picked up the glucometer, informed R3 of the results and went out of the room. At 12:28 PM, V15 used the micro-kill wipes again on the glucometer, wiping the glucometer for 5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wheelchair foot rests were in place for a resident during transport and failed to ensure a resident's medication was secured. This applies to 2 of 9 residents (R77, R74) in the sample of 49. The findings include: 1. R77's admission Record (Face Sheet) showed an admission date of 7/7/23 with diagnoses to include Alzheimer's (dementia), muscle weakness, osteoarthritis, history of falling, osteoporosis, and weakness. R77's Care Plan showed she was a mechanical lift transfer. R77's 6/11/25 Minimum Data Set (MDS) showed she required Partial/Moderate assistance for wheelchair transports of 50 feet and she was totally dependent upon staff for transport of 150 feet. On 8/26/2025 at 12:12 PM, R77 was in the central common area of the locked memory care unit. R77 was in her wheelchair. V3 Agency Certified Nursing Assistant (CNA) transported R77 to the dining area. As V3 pushed R77 in her wheelchair, R77's right foot was dragging and skipping…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to keep a resident's urinary catheter off of the floor; failed to keep catheter tubing below the level of the resident's bladder, and failed to have orders or diagnoses in place for an indwelling catheter. This applies to 2 of 3 residents (R43, R128) reviewed for urinary catheters in the sample of 49. The findings include: 1. R43's Face Sheet showed an admission date of 11/10/24 with diagnoses to include dementia, interstitial cystitis (bladder pain and/or urgency), and urinary retention. R43' Care Plan showed [R43] has a UTI (urinary tract infection) and is at risk for recurrent UTI's.(11/18/24) On 08/26/2025 at 11:50 AM, R43 was sitting in her wheelchair in the common area on the locked memory care unit. R43's catheter tubing exited her lower pant leg and discharged into a catheter bag suspended under the seat of her wheelchair. At least 18 inches of R43's catheter tubing was laying on the floor. In the middle of the tubing was a clip. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R9) reviewed for oxygen in the sample of 49. The findings include: R9's face sheet dated 8/28/25 showed diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, emphysema, cerebral atherosclerosis, and dependence of supplemental oxygen. R9's facility assessment dated [DATE] showed severe cognitive impairment. R9's order summary report dated 8/28/25 showed an order for oxygen at three liters via nasal cannula every shift for dyspnea (difficulty or shortness of breath), start dated 7/22/25. R9's care plan showed a focus area for the risk of acute exacerbation of COPD and the use of oxygen at two liters per nasal cannula (initiated 5/13/25). The same care plan showed to administer the oxygen at two liters per continuous nasal cannula per physician orders. On 8/27/25 at 10:05 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure range of motion was implemented for a resident with functional limitations and failed to ensure an assistive device was in place for a resident with a contracture for four of four residents (R19, R38, R1 and R6) reviewed for range of motion in a sample of 40. Findings include: The facility's Range of Motion and Contractor Assessment and Preventions policy, dated 10/2019, documents that the objectives of range of motion exercise is to preserve resident's present range of motion. 1. R19's Restorative Program Note, dated 9/11/24, documents that R19 requires AAROM, active range of motion program, along with dressing and grooming. R19's Functional Abilities and Goals, dated 9/11/24, documents that R19's has an impairment to one side of her upper extremities. This form documents that R19 required substantial/maximal assistance for activities of daily living. On 10/24/24 at 10:15 AM, R19's Rehab/Restorative Assessment, dated 9/11/24, active assist range of motion-to prevent limitations, to be performed BID…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of three residents (R103) reviewed for PASARR screening, in the sample of 40. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), dated (effective) 11/18/2023 documents, This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. This includes incorporating the recommendations from the PASARR level 11 determination and evaluation in the residents' assessment, care plan and transition of care; and referring all level 11 residents and all residents with new or evident conditions related to Level 11 review upon significant change in status assessment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2024-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide grooming assistance for one of three residents (R12) reviewed for activities of daily living assistance in a sample of 40. Findings Include: The facility policy, ADL (Activities of Daily Living) Care, dated 11/2015 directs staff, To meet the grooming and hygiene needs of residents with dignity and privacy. Shaving: If the resident is a woman, shave only the areas with facial hair and apply moisturizer instead of aftershave. R12's current Physician Order Sheet, dated October 2024 documents the following diagnoses: Vascular Dementia, Osteoporosis, Cervical Spondylolysis, Polyosteoarthritis, Polymyalgia Rheumatica, Rheumatoid Arthritis and Weakness. R12's current Care Plan, dated 10/15/2024 includes the following Focus areas: (R12) has a deficit in ADL (Activities of Daily Living), physical mobility and requires staff moderate to total assistance from staff. (R12) has generalized weakness, impaired balance, strength and endurance. Also included are the following Interventions: Assist with dressing and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the staff covered hair in a sanitary manner while in the kitchen. This failure has the potential to affect all 124 residents at the facility. Findings include: The facility's Hair Restraints/Jewelry/Nail Polish/False Eyelashes Policy, Dated 2017, documents: Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. On 9/26/23 at 10:25am, V6 Dietary Manager was observed with staff in the facility kitchen. V6's hair on the back of her head was uncovered. V10 [NAME] and V11 [NAME] were preparing the facility's lunch meal for residents. V10 and V11 were observed to have hair uncovered on the sides and/or back of their heads. On 9/26/23 at 10:25am, V6 Dietary Manager and V10 [NAME] stated that for kitchen staff, all their hair was supposed to be covered. V6 stated, I have been running around a lot and it came out. On 9/27/23 at 2:05pm, V6 Dietary Manager stated: Anyone who enters the kitchen should have a hairnet on and staff should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-29 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to revise Care Plans to be resident specific for five (R10, R12, R20, R78, and R108) of 25 residents reviewed for Care Plan revision in a sample of 31. Findings include: The facility's Care Plans, Comprehensive Person-Centered Policy, dated 4/2017, documents Policy Statement: A comprehensive, person-centered care pan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. On 9/26/23 at 11:13am and on 9/28/23 at 11:00am, R12 was lying in bed with her CPAP (Continuous Positive Airway Pressure) mask on and machine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a respiratory treatment was administered according to facility policy for one (R54) of one residents reviewed for breathing treatments during medication administration; and failed to ensure a residents respiratory equipment is routinely cleaned for two (R12 and R78) of four residents reviewed for respiratory care in a sample of 31. Findings include: 1. The facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 11/2013, documents The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds .16. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. When treatment is complete turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .23. Obtain post-treatment pulse, respiratory rate and lung sounds. 24. Rinse nebulizer pieces after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a diagnosis, targeted behaviors, and indication for the use of an antipsychotic medication was in place for a resident with Dementia for one (R10) and failed to ensure a PRN (as needed) psychotropic medication did not exceed a duration of 14 days without a physician evaluation and rationale for continued use for one (R20) of five residents reviewed for unnecessary medications in the sample of 31. Findings include: The facility's Psychotropic Medication policy and procedure, dated 11/2013, defines This same policy defines A psychotropic drug is any drug that affects brain activities associated with mental processed and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotics, anti-depressants, anti-anxiety and hypnotics. This same policy documents The prescribing and administration of psychotropic drugs is based on a comprehensive assessment of the resident. Residents who have not used psychotropic dugs are not given these dugs unless the medication is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PAVILION HEALTHCARE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 2.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 3.4 | -0.4 vs chain |
The other 4 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ILANA D AARON TRUST C/U MAURICE AARON 2014 FAMILY GIFT TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 12/19/2022 |
| ILANA D AARON TRUST C/U MAURICE AARON 2014 LEGACY GIFT TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 9% | since 12/19/2022 |
| EMST LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| JONATHAN H AARON REVOCABLE TRUST | Organization | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| GOLDSTEIN, SHIMON | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| GRAF, MARCELLA | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/19/2022 |
| GROSS, SHOSHANA | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| KROLL, GABRIEL | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| PROCTOR, KATHERINE | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| RIPSTEIN, KENNETH | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| AARON, JONATHAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/19/2022 |
| ROBIN, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| WETZEL, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| STERN, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/24/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145426. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.